AI-powered clinical decision support (AI-CDS) is moving fast from novelty to infrastructure, embedded directly into the EHRs and workflows clinicians use every day. But most of the underlying models are trained predominantly on international evidence (often US or UK guidelines) that can conflict ma…

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Background  Although care pathways are a response to the calls for a major change in health system redesign initiatives, very few articles have proposed an implementation method. Indeed, no method exi...

This article summarises the background and benefits of community HealthPathways, and offers tips on using this tool.

In this paper, we make a distinction between spreading and scaling innovations and spreading and scaling good practices for improvement, as many healthcare change practitioners often feel there is a “...

Background Staff in health systems everywhere have exhibited flexibility and a capacity for improvisations during, and in response to, the COVID-19 pandemic. Looking to other examples of such resilient behaviours outside of those induced by the pandemic is instructive for those involved with researching or understanding change, or making health systems improvements. Methods Here, we synthesise and then assess the value of eight case studies of in situ resilient performance from Canada, Sweden, Japan, Belgium, the United Kingdom, Norway, the United States and Brazil. The cases are divided into four categories: responsiveness to a crisis; adaptiveness over time; local adoption in accommodating to a top down, national policy change; and the consequential outcomes of an intervention. Results The cases illuminate the resourcefulness of translational and social researchers in examining such behaviours and practices. More than that, they also foreground the ingenuity and adaptive capacity of staff on-the-ground who continually anticipate, respond and adapt to make systems work and provide continuous care in the face of many challenges, including resource deficiencies, policy misalignments, and new technologies, policies and procedures that need to be integrated into local workflows. Front line clinicians make care systems work, pre-empting issues and sorting out problems before they occur or as they arise. Conclusions A key lesson amongst a range of findings is that, rather than focusing on shiny new tools of change (checklists, frameworks, policy mandates), it is much more insightful and satisfying to deeply apprehend care at the sharp end, where clinicians deliver care to patients, understanding how everyday work is executed. This, rather than the Health Ministry, the Boardroom, or the Management Consultant’s office, is where and how change is being enabled, and where street level actors solve problems, thwart issues in advance, and constantly avoid pitfalls.

This Viewpoint discusses approaches to address clinician occupational well-being based on data and experiences before and during the COVID-19 pandemic.

Background Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. Objective To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. Design Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. Participants Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017–2018 National Health and Nutrition Examination Survey. Main Measures The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. Key Results PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). Conclusions PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.

Glyn Elwyn and colleagues highlight the potential benefits of fast and frugal knowledge tools Jan is a 42-year-old plumber, originally from Poland. He tells his family doctor that he’s had low back pain, going down the back of his leg and making it painful to walk. He takes drugs for psoriasis and high blood pressure. He smokes five cigarettes a day (down from 20 a year ago). He went through a long period of depression after his first child was stillborn three years ago and still has days when he feels very low. He and his wife are keen to have another child but she has not become pregnant. Amanda has been Jan’s family doctor for many years. She works full time, typically seeing 30 patients a day and doing much of the administration. She went on a one week update course recently, in which specialists presented the latest evidence on 15 clinical topics. She sees the occasional pharmaceutical representative and skims the abstracts in two journals regularly. She is a member of an online social media (Facebook) group where she shares ideas and (with consent) fragments of real patient cases with her peers. She joins this group twice a day and finds it a source of usable knowledge and support. The various guidelines relevant to Jan’s acute and chronic conditions exceed 500 pages.1 2 3 4 5 6 7 Amanda does not consult any of these guidelines. An experienced practitioner using knowledge that is primarily intuitive and applied through heuristics (rules of thumb),8 she asks Jan a few questions about his back pain and examines him. While doing so, she notices that his psoriasis is quiescent and also checks his blood pressure. She offers him non-steroidal anti-inflammatory drugs and asks him to return in a few days …

Background Healthcare systems may be resilient and adaptive, but they are not fit for purpose in their current state. Increasing threats to health system sustainability have underscored the need to move towards a learning health system in which research and data are used routinely in clinical practice to facilitate system improvement. This study aimed to establish which elements of the learning health system were being realised within a university-based general practice and determine acceptability from staff to embrace further the transition towards a learning health system. Methods Semi-structured interviews were conducted with practice staff, including clinical and administrative staff, to determine the current state of the learning health system in the practice. An embedded researcher was placed within the general practice on a part-time basis to investigate the learning health system model. Interviews were transcribed and thematically analysed based on the National Academy of Medicine’s framework of learning health systems. Results In total, 32 (91%) practice staff were interviewed, comprising general practitioners (n = 15), nurses (n = 3), administrative staff (n = 13), and a psychologist (n = 1). Participants indicated that the practice was operating with several characteristics of a learning health system (e.g., emphasising science and informatics; focusing on patient-clinician partnerships; applying incentives; supporting a continuous learning culture; and establishing structures and governance for learning). These measures were supported by the university-based setting, and resultant culture of learning. Nevertheless, there were areas of the practice where the learning health system could be strengthened, specifically relating to the use of patient data and informatics. Staff generally expressed willingness to engage with the process of strengthening the learning health system within their practice. Conclusion Although the idea of a learning health system has been gaining traction in recent years, there are comparatively few empirical studies presented in the literature. This research presents a case study of a general practice that is operating as a learning health system and highlights the utility of using the learning health system framework.

When David Meates became CEO of New Zealand's Canterbury District Health Board in 2009, he took charge of a system that was "broken and fragmented". 11 years later, the system's fortunes were transformed, with it recognised as one of the most integrated healthcare systems anywhere in the world. At a recent Public Policy Projects dinner event, Meates shared his experiences and lessons from Canterbury's transformation, providing vital insight for the NHS as it continues its journey from fragmentation to integration.

Expanding disease definitions are causing more and more previously healthy people to be labelled as diseased, contributing to the problem of overdiagnosis and related overtreatment. Often the specialist guideline panels which expand definitions have close tis to industry and do not investigate the harms of defining more people as sick. Responding to growing calls to address these problems, an international group of leading researchers and clinicians is proposing a new way to set diagnostic thresholds and mark the boundaries of condition definitions, to try to tackle a key driver of overdiagnosis and overtreatment. The group proposes new evidence-informed principles, with new process and new people constituting new multi-disciplinary panels, free from financial conflicts of interest. Expanding definitions of disease are causing too many people to be diagnosed and treated unnecessarily, producing harm and waste, posing a major threat to human health and the sustainability of health systems, and creating growing conflict within medicine.1 2 For example, the widely used definition of ‘chronic kidney disease’ labels around half of all older people, yet many of them will never experience related symptoms.3 Changes to the definition of gestational diabetes could double its prevalence, despite a lack of clear evidence that the expansion will bring the newly diagnosed meaningful benefits that outweigh harms.4 Recently, a new definition of hypertension which labels one in every two adults, while welcomed by some, has been soundly rejected by family doctors over concerns it may cause more harm than good to many people.5 Responding to growing calls for action to address this key driver of overdiagnosis, from professional societies and other groups around the globe,2 6 7 we are proposing a new primary care-led, multidisciplinary, independent, people-centred approach to defining disease. ### The unmet need for reform An ongoing series about overdiagnosis in the BMJ has documented global …

Background Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called “postcode lottery” of care. The original aim of this study—to examine the nature of quality in long covid care and reduce unwarranted variation in services—evolved to focus on examining the reasons why standardizing care was so challenging in this condition. Methods In 2021–2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge. Results Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). Conclusion Not all variation in long covid services is unwarranted. Largely because long covid’s manifestations are so varied and comorbidities common, generic “evidence-based” standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients’ unique needs. Study registration NCT05057260, ISRCTN15022307.